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Liu X, Lang B, Zeng L, Huang L, Chen S, Jia ZJ, Cheng G, Yu Q, Zhang L. Comparison of the effects of ketamine via nebulization versus different pharmacological approaches in pediatric sedation: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2023; 23:375. [PMID: 37974083 PMCID: PMC10652489 DOI: 10.1186/s12871-023-02298-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/27/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Nebulized drug delivery is commonly used in pediatric clinical practice. The growing number of literatures have reported the application of nebulized ketamine in pediatric sedation in recent years. This meta-analysis of randomized controlled trials comparing the efficacy and safety of nebulized ketamine versus different pharmacological approaches was conducted to estimate the effects of this technique in pediatric sedation. METHODS We searched PubMed, Embase, and Cochrane Library from inception to Feb 2023. All randomized controlled trials used nebulized ketamine as presurgical and pre-procedural sedatives in children were included. Sedative effects and various adverse events were considered as the outcomes. RESULTS Ten studies with 727 pediatric patients were enrolled. Compared to nebulized dexmedetomidine, using of ketamine via nebulization showed similar sedation satisfaction (54.79% vs. 60.69%, RR = 0.88, with 95%CI [0.61, 1.27]), success rate of parental separation (57.27% vs. 73.64%, RR = 0.81, with 95%CI [0.61, 1.08]), and mask acceptability (37.27% vs. 52.73%, RR = 0.71, with 95%CI [0.45, 1.10]). However, the using of combination of two medications (nebulized ketamine plus nebulized dexmedetomidine) was associated with better sedative satisfaction (33.82% vs. 68.11%, RR = 0.50, with 95%CI [0.27, 0.92]) and more satisfactory mask acceptance (45.59% vs. 71.01%, RR = 0.69, with 95%CI [0.56, 0.86]). Compared with nebulized ketamine, using of nebulized dexmedetomidine was associated with less incidence of emergence agitation (18.18% vs. 3.33%, RR = 4.98, with 95%CI [1.88, 13.16]). CONCLUSIONS Based on current evidences, compared to nebulized dexmedetomidine, nebulized ketamine provides inconspicuous advantages in pediatric sedation, and it has a relatively high incidence of emergence agitation. Combination of nebulized ketamine and dexmedetomidine might be considered as one preferred option in pediatric sedation as it can provide more satisfactory sedative effects. However, there is insufficient evidence regarding nebulized ketamine versus ketamine administered through other routes and nebulized ketamine versus other sedatives. The overall low or moderate quality of evidence evaluated by the GRADE system also calls for more high-quality studies with larger sample sizes in future. RESEARCH REGISTRATION The protocol of present study was registered with PROSPERO (CRD42023403226).
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Affiliation(s)
- Xiao Liu
- Department of Pharmacy, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, China
| | - Bingchen Lang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Liang Huang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
| | - Shouming Chen
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhi-Jun Jia
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Guo Cheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Laboratory of Molecular Translational Medicine, Center for Translational Medicine, Sichuan University, Chengdu, China
| | - Qin Yu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China
- National Drug Clinical Trial Institute, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.
- National Medical Products Administration (NMPA) Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, China.
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.
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Sohnen S, Dowling O, Shore-Lesserson L. Single dose perioperative intrathecal ketamine as an adjuvant to intrathecal bupivacaine: A systematic review and meta-analysis of adult human randomized controlled trials. J Clin Anesth 2021; 73:110331. [PMID: 33962333 DOI: 10.1016/j.jclinane.2021.110331] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To identify whether adding intrathecal ketamine to intrathecal bupivacaine prolongs the time to first analgesic request in adult humans. DESIGN A meta-analysis of randomized controlled trials in humans. SETTING The majority of data was obtained in an operating room and postoperative recovery area. PATIENTS A total of 750 ASA physical status I and II patients were included in the study. Procedures performed include: cesarean section, lower abdominal surgery, lower limb surgery, and urologic surgery. INTERVENTIONS Databases including PubMed, Embase, Web of Science, and Cochrane were searched. Google Scholar was also queried. Multiple reviewers screened the papers for inclusion. MEASUREMENTS The primary outcome assessed was time to first analgesic request. Secondary outcomes included onset of sensory blockade, onset of motor blockade, duration of sensory blockade, and duration of motor blockade. Data were extracted to include means, 95% confidence intervals, tests for heterogeneity, and use of the Cochrane Collaboration guidelines to assess for publication bias. MAIN RESULTS Eleven randomized controlled trials met inclusion criteria. When comparing intrathecal bupivacaine plus ketamine to intrathecal bupivacaine alone, the time to first analgesic request was prolonged (effect size = 58.23 min (95% CI 37.36 to 79.10) p < 0.0001). Secondary outcomes showed the onset time of sensory blockade was shortened (effect size = -0.87 min (95% CI -1.361 to 0.378) p = 0.0005), the onset time of motor blockade was reduced (effect size = -0.88 min (95% CI -1.77 to 0.013) p = 0.05), the duration of sensory blockade was prolonged (effect size = 39.73 min (95% CI 15.97 to 63.50) p = 0.001), and the duration of motor blockade was prolonged (effect size = 4.02 min (95% CI 3.27 to 4.78) p < 0.0001). Studies were shown to have high heterogeneity. Egger tests for all outcomes were non-significant and funnel plots assessing publication bias were all asymmetrical. CONCLUSIONS The studies analyzed suggest there may be a benefit to using intrathecal ketamine as an adjunct to bupivacaine. Additional studies are warranted to optimize dosing, clarify the safety and efficacy of this intrathecal drug combination, and examine the various ketamine formulations as intrathecal bupivacaine adjuvants.
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Affiliation(s)
- Samantha Sohnen
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America.
| | - Oonagh Dowling
- Zucker School of Medicine at Hofstra/Northwell, Department of Anesthesiology, Northwell Health, New Hyde Park, NY, United States of America
| | - Linda Shore-Lesserson
- Zucker School of Medicine at Hofstra/Northwell, Department of Anesthesiology, Northwell Health, New Hyde Park, NY, United States of America
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Carpi CA, Neto AGG, Gusmão RA, Silva TAM, Gomez MV, Castro-Junior CJ. Intrathecal Morphine Versus Ketamine in Postoperative Pain After Hysterectomy: Double-Blinded, Randomized Clinical Trial. J Perianesth Nurs 2020; 35:580-585.e2. [PMID: 32855054 DOI: 10.1016/j.jopan.2020.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Abdominal hysterectomy is one of the most commonly performed gynecologic surgical procedures and is frequently associated with moderate to severe pain. The present study compared the effects of morphine and ketamine on postoperative analgesia, hemodynamic stability, and postoperative adverse effects in patients who underwent abdominal hysterectomy. DESIGN This randomized controlled trial compares the effects of morphine plus adjuvants to those of ketamine plus adjuvants, administered as spinal anesthetic agents in patients who underwent abdominal hysterectomy. METHODS Eighty patients were randomly assigned to two different groups: group M (morphine, 40 mcg) and group K (ketamine, 20 mg); the anesthetic agents were combined with equal quantities of other adjuvants. Postoperative analgesia was evaluated by means of a numeric pain rating scale; adverse effects (pruritus, nausea and vomiting, urinary retention, respiratory depression, and changes in bowel habits) at specific postoperative time intervals of T1 (4 hours), T2 (12 hours), and T3 (24 hours) were documented and compared. Hemodynamic stability was assessed intraoperatively. FINDINGS Both groups displayed similar patient characteristics, comorbidities, paravertebral block level, and intraoperative hemodynamics. The present study observed a significant difference in postoperative analgesia between the two groups, 12 hours after the surgery, with group M exhibiting better results, compared with group K (P = .004). The pain scores obtained from group K were consistent with the amount of rescue medication (tramadol) administered to the subjects in the group, which showed a concomitant higher consumption of tramadol, compared with group M (42.5 and 71.8 mg in group M and group K, respectively, P = .011). Group M showed a higher incidence of pruritus, changes in bowel habits, and constipation compared with group K. CONCLUSIONS Compared with ketamine, intrathecal morphine obtained better postoperative analgesia up to 12 hours after surgery, with a higher incidence of pruritus without any significant change in other variables.
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Affiliation(s)
- Camila A Carpi
- Department of Anesthesiology, Hospital São José do Avaí, Itaperuna, Rio de Janeiro, Brazil
| | - Alahyr G G Neto
- Department of Anesthesiology, Hospital São José do Avaí, Itaperuna, Rio de Janeiro, Brazil
| | - Rodrigo A Gusmão
- Department of Anesthesiology, Hospital São José do Avaí, Itaperuna, Rio de Janeiro, Brazil
| | - Thaís A M Silva
- Department of Neurotransmitters, Institute of Education and Research, Santa Casa, Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Marcus V Gomez
- Department of Neurotransmitters, Institute of Education and Research, Santa Casa, Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Célio J Castro-Junior
- Department of Neurotransmitters, Institute of Education and Research, Santa Casa, Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.
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Abd El-Rahman AM, Mohamed AA, Mohamed SA, Mostafa MAM. Effect of Intrathecally Administered Ketamine, Morphine, and Their Combination Added to Bupivacaine in Patients Undergoing Major Abdominal Cancer Surgery a Randomized, Double-Blind Study. PAIN MEDICINE 2019; 19:561-568. [PMID: 28520955 DOI: 10.1093/pm/pnx105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Effective postoperative pain control reduces postoperative morbidity. In this study, we investigated the effects of intrathecal morphine, ketamine, and their combination with bupivacaine for postoperative analgesia in major abdominal cancer surgery. Study Design Prospective, randomized, double-blind. Setting Academic medical center. Patients and Methods Ninety ASA I-III patients age 30 to 50 years were divided randomly into three groups: the morphine group (group M) received 10 mg of hyperbaric bupivacaine 0.5% in 2 mL volume and 0.3 mg morphine in 1 mL volume intrathecally. The ketamine group (group K) received 0.1 mg/kg ketamine in 1 mL volume instead of morphine. The morphine + ketamine group (group K + M) received both 0.3 mg morphine and 0.1 mg/kg ketamine in 1 mL volume intrathecally. Postoperative total morphine consumption, first request of analgesia, visual analog score (VAS), and side effects were recorded. Results Total PCA morphine was significantly decreased in group M + K compared with groups M and K. Time to first request of analgesia was prolonged in groups M and M + K compared with group K (P < 0.001). VAS in group M + K was reduced from two to 24 hours, and in group M from 12 and 18 hours postoperation compared with group K, with an overall good analgesia in the three groups. Sedation was significantly higher in group M + K compared with group M until six hours postoperation. No other side effects were observed. Conclusions Adding intrathecal ketamine 0.1 mg/kg to morphine 0.3 mg in patients who underwent major abdominal cancer surgery reduced the total postoperative morphine consumption in comparison with either drug alone, with an overall good postoperative analgesia in all groups, with no side effects apart from sedation.
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Affiliation(s)
- Ahmad M Abd El-Rahman
- Department of anesthesia, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Ashraf A Mohamed
- Department of anesthesia, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Sahar A Mohamed
- Department of anesthesia, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Mohamed A M Mostafa
- Department of anesthesia, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
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Schlatter J, Nguyen D, Zamy M, Kabiche S, Fontan JE, Cisternino S. Safety of intrathecal route: focus to methylprednisolone acetate (Depo-Medrol) use. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 28:21-30. [DOI: 10.1007/s00586-017-5387-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/24/2017] [Accepted: 11/05/2017] [Indexed: 11/24/2022]
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Kaye AD, Fox CJ, Padnos IW, Ehrhardt KP, Diaz JH, Cornett EM, Chandler D, Sen S, Patil S. Pharmacologic Considerations of Anesthetic Agents in Pediatric Patients: A Comprehensive Review. Anesthesiol Clin 2017; 35:e73-e94. [PMID: 28526162 DOI: 10.1016/j.anclin.2017.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Acute pain in the pediatric population has important differences in terms of biology, intrapopulation variation, and epidemiology. Discussion as to the pharmacologic considerations of anesthetic agents, such as induction agents, neuromuscular blockers, opioids, local anesthetics, and adjuvant agents, is presented in this article. Special considerations and concerns, such as risk for propofol infusion syndrome and adverse potential side effects of anesthesia agents, are discussed. Anesthesiologists managing pediatric patients need to have a firm understanding of physiologic and pharmacologic differences compared with the adult population. Future studies to improve the understanding of pharmacokinetics in the pediatric population are needed.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Science Center, Room 659, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Charles J Fox
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932, USA
| | - Ira W Padnos
- Department of Anesthesiology, Louisiana State University Health Science Center, Room 659, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Ken P Ehrhardt
- Department of Anesthesiology, Louisiana State University Health Science Center, Room 659, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - James H Diaz
- Department of Anesthesiology, Louisiana State University Health Science Center, Room 659, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Science Center, Room 659, 1542 Tulane Avenue, New Orleans, LA 70112, USA; Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932, USA
| | - Debbie Chandler
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932, USA
| | - Sudipta Sen
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932, USA
| | - Shilpadevi Patil
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932, USA
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Schoevers RA, Chaves TV, Balukova SM, aan het Rot M, Kortekaas R. Oral ketamine for the treatment of pain and treatment-resistant depression†. Br J Psychiatry 2016; 208:108-13. [PMID: 26834167 DOI: 10.1192/bjp.bp.115.165498] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Recent studies with intravenous (i.v.) application of ketamine show remarkable but short-term success in patients with MDD. Studies in patients with chronic pain have used different ketamine applications for longer time periods. This experience may be relevant for psychiatric indications. AIMS To review the literature about the dosing regimen, duration, effects and side-effects of oral, intravenous, intranasal and subcutaneous routes of administration of ketamine for treatment-resistant depression and pain. METHOD Searches in PubMed with the terms 'oral ketamine', 'depression', 'chronic pain', 'neuropathic pain', 'intravenous ketamine', 'intranasal ketamine' and 'subcutaneous ketamine' yielded 88 articles. We reviewed all papers for information about dosing regimen, number of individuals who received ketamine, number of ketamine days per study, results and side-effects, as well as study quality. RESULTS Overall, the methodological strength of studies investigating the antidepressant effects of ketamine was considered low, regardless of the route of administration. The doses for depression were in the lower range compared with studies that investigated analgesic use. Studies on pain suggested that oral ketamine may be acceptable for treatment-resistant depression in terms of tolerability and side-effects. CONCLUSIONS Oral ketamine, given for longer time periods in the described doses, appears to be well tolerated, but few studies have systematically examined the longer-term negative consequences. The short- and longer-term depression outcomes as well as side-effects need to be studied with rigorous randomised controlled trials.
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Affiliation(s)
- Robert A Schoevers
- Robert A. Schoevers, MD PhD, Tharcila V. Chaves, MSc, Sonya M. Balukova, MSc, University of Groningen, University Medical Center Groningen, Department of Psychiatry, Research School of Behavioural and Cognitive Neurosciences (BCN), Interdisciplinary Center for Psychopathology and Emotion Regulation (ICPE), Groningen; Marije aan het Rot, PhD, Department of Psychology and Research School of Behavioral and Cognitive Neurosciences; Rudie Kortekaas, PhD, Department of Psychiatry, Interdisciplinary Center for Psychopathology and Emotion Regulation, Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tharcila V Chaves
- Robert A. Schoevers, MD PhD, Tharcila V. Chaves, MSc, Sonya M. Balukova, MSc, University of Groningen, University Medical Center Groningen, Department of Psychiatry, Research School of Behavioural and Cognitive Neurosciences (BCN), Interdisciplinary Center for Psychopathology and Emotion Regulation (ICPE), Groningen; Marije aan het Rot, PhD, Department of Psychology and Research School of Behavioral and Cognitive Neurosciences; Rudie Kortekaas, PhD, Department of Psychiatry, Interdisciplinary Center for Psychopathology and Emotion Regulation, Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sonya M Balukova
- Robert A. Schoevers, MD PhD, Tharcila V. Chaves, MSc, Sonya M. Balukova, MSc, University of Groningen, University Medical Center Groningen, Department of Psychiatry, Research School of Behavioural and Cognitive Neurosciences (BCN), Interdisciplinary Center for Psychopathology and Emotion Regulation (ICPE), Groningen; Marije aan het Rot, PhD, Department of Psychology and Research School of Behavioral and Cognitive Neurosciences; Rudie Kortekaas, PhD, Department of Psychiatry, Interdisciplinary Center for Psychopathology and Emotion Regulation, Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marije aan het Rot
- Robert A. Schoevers, MD PhD, Tharcila V. Chaves, MSc, Sonya M. Balukova, MSc, University of Groningen, University Medical Center Groningen, Department of Psychiatry, Research School of Behavioural and Cognitive Neurosciences (BCN), Interdisciplinary Center for Psychopathology and Emotion Regulation (ICPE), Groningen; Marije aan het Rot, PhD, Department of Psychology and Research School of Behavioral and Cognitive Neurosciences; Rudie Kortekaas, PhD, Department of Psychiatry, Interdisciplinary Center for Psychopathology and Emotion Regulation, Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudie Kortekaas
- Robert A. Schoevers, MD PhD, Tharcila V. Chaves, MSc, Sonya M. Balukova, MSc, University of Groningen, University Medical Center Groningen, Department of Psychiatry, Research School of Behavioural and Cognitive Neurosciences (BCN), Interdisciplinary Center for Psychopathology and Emotion Regulation (ICPE), Groningen; Marije aan het Rot, PhD, Department of Psychology and Research School of Behavioral and Cognitive Neurosciences; Rudie Kortekaas, PhD, Department of Psychiatry, Interdisciplinary Center for Psychopathology and Emotion Regulation, Department of Neuroscience, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Tormey WP. Newspaper reports from the Coroners Court in Ireland are used to reveal the potential complexity and need for reform in forensic toxicology and medicine services. J Forensic Leg Med 2015; 32:47-52. [DOI: 10.1016/j.jflm.2015.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/21/2015] [Indexed: 10/23/2022]
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Abdolmohammadi S, Hétu PO, Néron A, Blaise G. Efficacy of an intrathecal multidrug infusion for pain control in older adults and in end-stage malignancies: A report of three cases. Pain Res Manag 2015; 20:118-22. [PMID: 25996762 PMCID: PMC4447152 DOI: 10.1155/2015/405630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The aim of the present study was to explore the effectiveness of an alternative method to manage pain based on a time-limited intrathecal (IT) infusion of an analgesic medication mixture. Three patients (69, 64 and 94 years of age) with intractable and poorly controlled pain due to bed sores, pelvic metastatic mass, and thoracic vertebra and rib fractures, respectively, were treated. Daily doses of opioids could not be increased due to side effects. An IT catheter (20 G) was placed by percutaneous approach in the lumbar area while advancing toward the thoracic region, and was then tunnelled and fixed subcutaneously. It was connected to an external infusion pump with a mixture of bupivacaine 1 mg⁄mL, naloxone 0.02 ng⁄mL, ketamine 100 µg⁄mL, morphine 0.01 mg⁄mL and clonidine 0.75 µg⁄mL. The starting rate was 1 mL⁄h. The pain was mostly controlled at a rate of <1 mL⁄h. Opioid consumption was reduced dramatically. The catheter was kept in place for one month in the first and third patients, and for six months in the second patient, until his death. Major side effects, such as hypotension, constipation, muscle weakness, sphincter dysfunction, and cognitive or mood deterioration, were not observed with this approach. One patient experienced a urinary tract infection followed by sepsis and meningitis, which was cured by antibiotics. The catheter was removed in this patient. IT infusion with a low-concentration multidrug mixture could be considered as an alternative modality for intractable pain relief in older adults or in malignancies.
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Affiliation(s)
- Sadegh Abdolmohammadi
- Department of Anesthesiology and Pain Clinic, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Pierre-Olivier Hétu
- Department of Biochemistry, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Andrée Néron
- Department of Pharmacy, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Gilbert Blaise
- Department of Anesthesiology and Medicine, Pain Clinic, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
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MCNICOL ED, SCHUMANN R, HAROUTOUNIAN S. A systematic review and meta-analysis of ketamine for the prevention of persistent post-surgical pain. Acta Anaesthesiol Scand 2014; 58:1199-213. [PMID: 25060512 DOI: 10.1111/aas.12377] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2014] [Indexed: 12/22/2022]
Abstract
While post-operative pain routinely resolves, persistent post-surgical pain (PPSP) is common in certain surgeries; it causes disability, lowers quality of life and has economic consequences. The objectives of this systematic review and meta-analysis were to evaluate the effectiveness of ketamine in reducing the prevalence and severity of PPSP and to assess safety associated with its use. We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE through December 2012 for articles in any language. We included randomized, controlled trials in adults in which ketamine was administered perioperatively via any route. Seventeen studies, the majority of which administered ketamine intravenously, met all inclusion criteria. The overall risk of developing PPSP was not significantly reduced at any time point in the ketamine group vs. placebo, nor did comparisons of pain severity scores reach statistical significance. Sensitivity analysis of exclusively intravenous ketamine studies included in this meta-analysis demonstrated statistically significant reductions in risk of developing PPSP at 3 and 6 months (P = 0.01 and P = 0.04, respectively). Adverse event rates were similar between ketamine and placebo groups. The study data from our review are heterogeneous and demonstrate efficacy of intravenously administered ketamine only in comparison with placebo. Highly variable timing and dosing of ketamine in these studies suggest that no unifying effective regimen has emerged. Future research should focus on clinically relevant outcomes, should stratify patients with pre-existing pain and possible central sensitization and should enroll sufficiently large numbers to account for loss to follow-up in long-term studies.
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Affiliation(s)
- E. D. MCNICOL
- Department of Anesthesiology and Pharmacy; Tufts Medical Center; Boston MA USA
| | - R. SCHUMANN
- Department of Anesthesiology; Tufts Medical Center; Boston MA USA
| | - S. HAROUTOUNIAN
- Department of Anesthesiology; Washington University in St Louis; St Louis MO USA
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Erol İM, Özdoğan L, Örnek D, Taşpınar V, Kalaycı D, Barçın S, Şahin F, Erk G, Dikmen B. Effect of Ketamine on the Quality of Anesthesia and Postoperative Analgesia in Epidural Anesthesia. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jecm.2014.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Turner M, Duncan J, Shah U, Metsvaht T, Varendi H, Nellis G, Lutsar I, Yakkundi S, McElnay J, Pandya H, Mulla H, Vaconsin P, Storme T, Rieutord A, Nunn A. Risk assessment of neonatal excipient exposure: lessons from food safety and other areas. Adv Drug Deliv Rev 2014; 73:89-101. [PMID: 24239480 DOI: 10.1016/j.addr.2013.11.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 09/25/2013] [Accepted: 11/06/2013] [Indexed: 11/26/2022]
Abstract
Newborn babies can require significant amounts of medication containing excipients intended to improve the drug formulation. Most medicines given to neonates have been developed for adults or older children and contain excipients thought to be safe in these age groups. Many excipients have been used widely in neonates without obvious adverse effects. Some excipients may be toxic in high amounts in which case they need careful risk assessment. Alternatively, it is conceivable that ill-founded fears about excipients mean that potentially useful medicines are not made available to newborn babies. Choices about excipient exposure can occur at several stages throughout the lifecycle of a medicine, from product development through to clinical use. Making these choices requires a scalable approach to analysing the overall risk. In this contribution we examine these issues.
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Ozdogan L, Sastim H, Ornek D, Postaci A, Ayerden T, Dikmen B. Neurotoxic effects of intrathecal magnesium sulphate. Rev Bras Anestesiol 2014; 63:139-43. [PMID: 23438808 DOI: 10.1016/s0034-7094(13)70205-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 02/27/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the potential neurotoxic effects at the ultrastructural level of magnesium sulfate administered intrathecally as a single or multi-dose. METHODS Our study was conducted with 24 Sprague-Dawley rats that weighed 250-300 g. After a 4-hour fast, the rats were given 10 mg.kg(-1) xylazine chloride intraperitoneal and then randomly allocated into three groups. Group I (n=8) received 0.9% normal saline, Group II (n = 8) was given one intrathecal injection of 0.02 mL of 15% magnesium sulphate, and Group III (n = 8) was given 0.02 mL of 15% magnesium sulphate once a day for seven days. The injections were given within 0.40 × 50 mm from the lumbar area. After seven days, the animals were sacrificed under anesthesia with an aortic injection of 10% formaldehyde and their tissues were fixed. The medulla spinalis was then examined and histopathologically evaluated under an electron microscope. The Kruskal-Wallis test was used for statistical evaluation. A value of p < .05 was considered to be statistically significant. RESULTS Significant neurodegeneration was detected in rats given single or repeated magnesium sulphate injections compared to the control group. The histopathological evaluation score of this group was also high. CONCLUSIONS Based on electron microscopic examination, we found that intrathecal magnesium sulphate administration induced neurodegeneration.
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Affiliation(s)
- Levent Ozdogan
- Anaesthesia and Reanimation Department, Ankara Numune Training and Research Hospital, Turkey
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Lee JY, Sim WS, Kim KM, Oh MS, Lee JE. The effect of ketamine as an additive in epidural block on the intractable herpetic neuralgia: a case report. Korean J Anesthesiol 2014; 66:64-6. [PMID: 24567816 PMCID: PMC3927004 DOI: 10.4097/kjae.2014.66.1.64] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 11/28/2012] [Accepted: 12/10/2012] [Indexed: 11/10/2022] Open
Abstract
Ketamine has been shown to have analgesic effect by blocking N-methyl-D-aspartate receptor, thus preventing and reducing central sensitization caused by peripheral nociceptive stimulation. However, due to lack of knowledge about its safety and toxicity in the central nervous system, either epidural or intrathecal injection of ketamine still remains controversial. Here, we describe a case report of satisfactory pain relief after the addition of ketamine in epidural injection in a patient with severe herpes zoster pain that was refractory to conventional medication, intravenous opioids and continuous epidural block. This case indicates the viability of epidural ketamine injection in patients with intractable herpetic neuralgia.
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Affiliation(s)
- Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Seok Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Eun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Evaluation of the analgesic effect of ketamine as an additive to intrathecal bupivacaine in patients undergoing cesarean section. ACTA ACUST UNITED AC 2014; 51:155-60. [PMID: 24529671 DOI: 10.1016/j.aat.2013.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 09/30/2013] [Accepted: 10/03/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Nowadays, conventional analgesic agents, which are widely used for pain relief after cesarean section, provide suboptimal analgesia with occasional serious side effects. We designed a randomized, double-blind, placebo-controlled study to evaluate the analgesic efficacy of intrathecal ketamine added to bupivacaine after cesarean section. METHODS Sixty patients scheduled for cesarean section under spinal anesthesia were randomly allocated to one of the two groups to receive either bupivacaine 10 mg combined with 0.1 mg/kg ketamine, or bupivacaine 10 mg combined with 0.5 mL distilled water intrathecally. The time to the first analgesic request, analgesic requirement in the first 24 hours after surgery, onset times of sensory and motor blockades, the durations of sensory and motor blockades, and the incidences of adverse effects such as hypotension, ephedrine requirement, bradycardia, and hypoxemia, were recorded. RESULTS Patients who received ketamine had a significantly prolonged duration of anesthesia compared with those who did not in the control group [95% confidence intervals (CI) 195-217; p = 0.001]. The mean time to the first analgesic request was also significantly longer in ketamine group (95% CI 252.5-275; p < 0.001). The total analgesic consumption in the 24 hours following surgery significantly lessened in the ketamine group compared with that of the control group (95% CI 2-2.5; p < 0.001). The two groups did not differ significantly in intraoperative and postoperative side effects. CONCLUSION Intrathecal ketamine 0.1 mg/kg co-administered with spinal bupivacaine elongated the time to the first analgesic request and lessened the total analgesic consumption in the first 24 postoperative hours in comparison with bupivacaine alone in the control group following elective cesarean delivery.
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Yousef GT, Ibrahim TH, Khder A, Ibrahim M. Enhancement of ropivacaine caudal analgesia using dexamethasone or magnesium in children undergoing inguinal hernia repair. Anesth Essays Res 2014; 8:13-9. [PMID: 25886097 PMCID: PMC4173573 DOI: 10.4103/0259-1162.128895] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Caudal analgesia is the most commonly used technique providing intra- and postoperative analgesia for various pediatric infraumbilical surgical procedures but with the disadvantage of short duration of action after single injection. Caudal dexamethasone and magnesium could offer significant analgesic benefits. We compared the analgesic effects and side-effects of dexamethasone or magnesium added to caudal ropivacaine in pediatric patients undergoing inguinal hernia repair. MATERIALS AND METHODS A total of 105 (1-6 years) were randomly assigned into three groups in a double-blinded manner. After a standardized sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.15% 1.5 mL/kg combined with either magnesium 50 mg in normal saline 1 mL (group RM), dexamethasone 0.1 mg/kg in normal saline 1 mL (group RD), or corresponding volume of normal saline (group R) according to group assignment. Postoperative analgesia, use of analgesics, and side-effects were assessed during the first 24 h. RESULTS Addition of magnesium or dexamethasone to caudal ropivacaine significantly prolonged analgesia duration 8 (5-11) h and 12 (8-16) h, respectively compared with 4 (3-5) h with the use of ropivacaine alone. The incidence of postoperative rescue analgesia was significantly higher in group R compared with groups RM and RD. The time to 1(st) analgesic dose was significantly longer in groups RM and RD (500 ± 190 and 730 ± 260 min) respectively compared with group R (260 ± 65 min). Group R patients achieved significantly higher Children's Hospital of Eastern Ontario Pain Scale and Faces Legs Activity Cry Consolability scores (4(th) hourly) compared with groups RM and RD patients (8(th) and 12(th) hourly, respectively). CONCLUSION The addition of dexamethasone or magnesium to caudal ropivacaine significantly prolonged the duration of postoperative analgesia in children undergoing inguinal hernia repair. Also the time to 1(st) analgesic dose was longer and the need for rescue postoperative analgesic was reduced and without increase in incidence of side effects.
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Affiliation(s)
- Gamal T. Yousef
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Tamer H. Ibrahim
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Khder
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Ibrahim
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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17
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Mion G, Marchetti F, Samama CM. [Compassionate use of intrathecal ketamine for intractable cancer pain]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2013; 32:621-622. [PMID: 23850219 DOI: 10.1016/j.annfar.2013.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/03/2013] [Indexed: 06/02/2023]
Affiliation(s)
- G Mion
- Service d'anesthésie, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France.
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18
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Neurotoxic effects of intrathecal magnesium sulphate. Braz J Anesthesiol 2013; 63:139-43. [PMID: 24565097 DOI: 10.1016/j.bjane.2012.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 02/27/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the potential neurotoxic effects at the ultrastructural level of magnesium sulfate administered intrathecally as a single or multi-dose. METHODS Our study was conducted with 24 Sprague-Dawley rats that weighed 250-300 g. After a 4-hour fast, the rats were given 10 mg.kg(-1) xylazine chloride intraperitoneal and then randomly allocated into three groups. Group I (n = 8) received 0.9% normal saline, Group II (n = 8) was given one intrathecal injection of 0.02 mL of 15% magnesium sulphate, and Group III (n = 8) was given 0.02 mL of 15% magnesium sulphate once a day for seven days. The injections were given within 0.40x50 mm from the lumbar area. After seven days, the animals were sacrificed under anesthesia with an aortic injection of 10% formaldehyde and their tissues were fixed. The medulla spinalis was then examined and histopathologically evaluated under an electron microscope. The Kruskal-Wallis test was used for statistical evaluation. A value of p < .05 was considered to be statistically significant. RESULTS Significant neurodegeneration was detected in rats given single or repeated magnesium sulphate injections compared to the control group. The histopathological evaluation score of this group was also high. CONCLUSIONS Based on electron microscopic examination, we found that intrathecal magnesium sulphate administration induced neurodegeneration.
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Shukla U, Prabhakar T, Malhotra K. Postoperative analgesia in children when using clonidine or fentanyl with ropivacaine given caudally. J Anaesthesiol Clin Pharmacol 2013; 27:205-10. [PMID: 21772681 PMCID: PMC3127300 DOI: 10.4103/0970-9185.81842] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The aim of the study was to compare the efficacy of clonidine and fentanyl as an additive to ropivacaine given via single shot caudal epidural in pediatric patients for postoperative pain relief. Materials and Methods: In the present double blind study, 90 children of ASA-I-II aged 3-8 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either ropivacaine 0.25% 1 ml/kg + clonidine 2 μg/kg (group I) or ropivacaine 0.25% 1 μl/kg + fentanyl 1 μg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamics, and side effects/complications. Results: Both the groups were similar with respect to patient and various block characteristics. The analgesic properties and hemodynamics were also comparable in both groups (P > 0.05). Side effects such as respiratory depression, vomiting bradycardia were significantly less in group I than group II (P < 0.05) ensuing more patient comfort. Conclusions: The analgesic properties of clonidine and fentanyl as additives to ropivacaine in single shot caudal epidural in children are comparable but clonidine offers a more favorable side effect profile. The use of clonidine as additive to ropivacaine in caudal epidural is superior choice to fentanyl because of lack of unwanted side effects and increased patient comfort.
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Affiliation(s)
- Usha Shukla
- Department of Anaesthesiology and Critical Care, U.P Rural Institute of Medical Sciences and Research, Saifai, Etawah, India
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20
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Johansson J, Sjöberg J, Nordgren M, Sandström E, Sjöberg F, Zetterström H. Prehospital analgesia using nasal administration of S-ketamine--a case series. Scand J Trauma Resusc Emerg Med 2013; 21:38. [PMID: 23672762 PMCID: PMC3660173 DOI: 10.1186/1757-7241-21-38] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 05/05/2013] [Indexed: 11/10/2022] Open
Abstract
Pain is a problem that often has to be addressed in the prehospital setting. The delivery of analgesia may sometimes prove challenging due to problems establishing intravenous access or a harsh winter environment. To solve the problem of intravenous access, intranasal administration of drugs is used in some settings. In cases where vascular access was foreseen or proved hard to establish (one or two missed attempts) on the scene of the accident we use nasally administered S-Ketamine for prehospital analgesia. Here we describe the use of nasally administered S-Ketamine in 9 cases. The doses used were in the range of 0,45-1,25 mg/kg. 8 patients were treated in outdoor winter-conditions in Sweden. 1 patient was treated indoor. VAS-score decreased from a median of 10 (interquartile range 8-10) to 3 (interquartile range 2-4). Nasally administered S-Ketamine offers a possible last resource to be used in cases where establishing vascular access is difficult or impossible. Side-effects in these 9 cases were few and non serious. Nasally administered drugs offer a needleless approach that is advantageous for the patient as well as for health personnel in especially challenging selected cases. Nasal as opposed to intravenous analgesia may reduce the time spent on the scene of the accident and most likely reduces the need to expose the patient to the environment in especially challenging cases of prehospital analgesia. Nasal administration of S-ketamine is off label and as such we only use it as a last resource and propose that the effect and safety of the treatment should be further studied.
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Affiliation(s)
- Joakim Johansson
- The Research and Development Unit, Jämtland County Council, Östersund, Sweden.
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21
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Laha A, Ghosh S, Das H. Comparison of caudal analgesia between ropivacaine and ropivacaine with clonidine in children: A randomized controlled trial. Saudi J Anaesth 2012; 6:197-200. [PMID: 23162389 PMCID: PMC3498654 DOI: 10.4103/1658-354x.101199] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Addition of clonidine to ropivacaine (0.2%) can potentially enhance analgesia without producing prolonged motor blockade. The aim of the present study was to compare the post-operative pain relieving quality of ropivacaine 0.2% and clonidine mixture to that of plain ropivacaine 0.2% following caudal administration in children. Methods: In a prospective, double-blinded, randomized controlled trial, 30 ASA 1 pediatric patients undergoing infraumbilical surgery were randomly allocated to receive a caudal injection of either plain ropivacaine 0.2% (1 ml/kg) (group A) or a mixture of ropivacaine 0.2% (1 ml/kg) with clonidine 2 μg/kg (group B). Objective pain score and need for supplemental analgesics were compared during the 1st 24 hours postoperatively. Residual post-operative sedation and motor blockade were also assessed. Results: Significantly prolonged duration of post-operative analgesia was observed in group B (P<0.0001). Heart rate and blood pressure were not different in 2 groups. Neither motor blockade nor post-operative sedation varied significantly between the groups. Conclusion: The combination of clonidine (2 μg/kg) and ropivacaine 0.2% was associated with an improved quality of post-operative analgesia compared to plain 0.2% ropivacaine. The improved analgesic quality of the clonidine-ropivacaine mixture was achieved without causing any significant degree of post-operative sedation or prolongation of motor blockade.
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Affiliation(s)
- Arpita Laha
- Department of Anaesthesiology, R. G. Kar Medical College, Kolkata, West Bengal, India
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Ghasemi M, Schachter SC. The NMDA receptor complex as a therapeutic target in epilepsy: a review. Epilepsy Behav 2011; 22:617-40. [PMID: 22056342 DOI: 10.1016/j.yebeh.2011.07.024] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 07/01/2011] [Accepted: 07/18/2011] [Indexed: 01/02/2023]
Abstract
A substantial amount of research has shown that N-methyl-D-aspartate receptors (NMDARs) may play a key role in the pathophysiology of several neurological diseases, including epilepsy. Animal models of epilepsy and clinical studies demonstrate that NMDAR activity and expression can be altered in association with epilepsy and particularly in some specific seizure types. NMDAR antagonists have been shown to have antiepileptic effects in both clinical and preclinical studies. There is some evidence that conventional antiepileptic drugs may also affect NMDAR function. In this review, we describe the evidence for the involvement of NMDARs in the pathophysiology of epilepsy and provide an overview of NMDAR antagonists that have been investigated in clinical trials and animal models of epilepsy.
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Affiliation(s)
- Mehdi Ghasemi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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23
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Schnabel A, Poepping DM, Kranke P, Zahn PK, Pogatzki-Zahn EM. Efficacy and adverse effects of ketamine as an additive for paediatric caudal anaesthesia: a quantitative systematic review of randomized controlled trials. Br J Anaesth 2011; 107:601-11. [PMID: 21846679 DOI: 10.1093/bja/aer258] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim of this quantitative systematic review was to assess the efficacy and adverse effects of ketamine added to caudal local anaesthetics in comparison with local anaesthetics alone in children undergoing urological, lower abdominal, or lower limb surgery. METHODS The systematic search, data extraction, critical appraisal, and pooled data analysis were performed according to the PRISMA statement. All randomized controlled trials (RCTs) were included in this meta-analysis and relative risk (RR), mean difference (MD), and the corresponding 95% confidence intervals (CIs) were calculated using the Revman(®) statistical software for dichotomous and continuous outcomes. RESULTS Thirteen RCTs (published between 1991 and 2008) including 584 patients met the inclusion criteria. There was a significant longer time to first analgesic requirements in patients receiving ketamine in addition to a local anaesthetic compared with a local anaesthetic alone (MD: 5.60 h; 95% CI: 5.45-5.76; P<0.00001). There was a lower RR for the need of rescue analgesia in children receiving a caudal regional anaesthesia with ketamine in addition to local anaesthetics (RR: 0.71; 95% CI: 0.44-1.15; P=0.16). CONCLUSIONS Caudally administered ketamine, in addition to a local anaesthetic, provides prolonged postoperative analgesia with few adverse effects compared with local anaesthetics alone. There is a clear benefit of caudal ketamine, but the uncertainties about neurotoxicity relating to the dose of ketamine, single vs repeated doses and the child's age, still need to be clarified for use in clinical practice.
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Affiliation(s)
- A Schnabel
- Department of Anesthesiology and Intensive Care, University Hospital of Münster, Albert-Schweitzer-Str. 33, 48149 Münster, Germany
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Truin M, Janssen SPM, van Kleef M, Joosten EAJ. Successful pain relief in non-responders to spinal cord stimulation: the combined use of ketamine and spinal cord stimulation. Eur J Pain 2011; 15:1049.e1-9. [PMID: 21565537 DOI: 10.1016/j.ejpain.2011.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/27/2011] [Accepted: 04/05/2011] [Indexed: 11/25/2022]
Abstract
Although spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain, still 30% of patients do not respond adequately to trial stimulation. These so called "non-responders" do not receive a permanent implantation for pain relief. The induction and maintenance of central sensitization plays a pivotal role in (chronic) neuropathic pain and is thought to be the resultant of the activation of the N-methyl-d-aspartate (NMDA) receptor in the dorsal horn. Blocking the NMDA receptor through the use of the non-competitive blocker ketamine has shown to attenuate neuropathic pain, although the undesirable side effects limit its use. The present study was performed to examine whether the combination of SCS with an individually determined sub-effective dose of intrathecal (i.t.) ketamine could convert non-responders into responders in rats with chronic neuropathic pain. Rats received a partial ligation of the sciatic nerve for the induction of neuropathic pain. Animals with tactile hypersensitivity to von Frey monofilaments (n=15) received 30 min of SCS. Non-responders to SCS (n=8) received their individually determined sub-effective i.t. dose of ketamine followed by 30 min of SCS. No side effects of the sub-effective dose of ketamine could be noted. The combined treatment of SCS and sub-effective dose of i.t. ketamine in non-responders resulted in a significant reduction of the withdrawal threshold in all previous non-responders to SCS, thereby converting them into responders to SCS.
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Affiliation(s)
- M Truin
- Pain Management and Research Center, Department of Anesthesiology, Maastricht University Hospital, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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Effects of intrathecal ketamine in the neonatal rat: evaluation of apoptosis and long-term functional outcome. Anesthesiology 2010; 113:147-59. [PMID: 20526188 DOI: 10.1097/aln.0b013e3181dcd71c] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Systemic ketamine can trigger apoptosis in the brain of rodents and primates during susceptible developmental periods. Clinically, spinally administered ketamine may improve the duration or quality of analgesia in children. Ketamine-induced spinal cord toxicity has been reported in adult animals but has not been systematically studied in early development. METHODS In anesthetized rat pups, intrathecal ketamine was administered by lumbar percutaneous injection. Changes in mechanical withdrawal threshold evaluated dose-dependent antinociceptive and carrageenan-induced antihyperalgesic effects in rat pups at postnatal day (P) 3 and 21. After intrathecal injection of ketamine at P3, 7, or 21, spinal cords were examined for apoptosis (Fluoro-Jade C and activated caspase-3), histopathologic change, and glial responses (ionized calcium-binding adapter molecule 1 and glial fibrillary acid protein). After maximal doses of ketamine or saline at P3 or P21, sensory thresholds and gait analysis were evaluated at P35. RESULTS Intrathecal injection of 3 mg/kg ketamine at P3 and 15 mg/kg at P21 reverses carrageenan-induced hyperalgesia. Baseline neuronal apoptosis in the spinal cord was greater at P3 than P7, predominantly in the dorsal horn. Intrathecal injection of 3-10 mg/kg ketamine in P3 pups (but not 15 mg/kg at P21) acutely increased apoptosis and microglial activation in the spinal cord and altered spinal function (reduced mechanical withdrawal threshold and altered static gait parameters) at P35. CONCLUSIONS Because acute pathology and long-term behavioral change occurred in the same dose range as antihyperalgesic effects, the therapeutic ratio of intrathecal ketamine is less than one in the neonatal rat. This measure facilitates comparison of the relative safety of spinally administered analgesic agents.
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Braun S, Gaza N, Werdehausen R, Hermanns H, Bauer I, Durieux ME, Hollmann MW, Stevens MF. Ketamine induces apoptosis via the mitochondrial pathway in human lymphocytes and neuronal cells. Br J Anaesth 2010; 105:347-54. [PMID: 20659914 DOI: 10.1093/bja/aeq169] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ketamine has been shown to have neurotoxic properties, when administered neuraxially. The mechanism of this local toxicity is still unknown. Therefore, we investigated the mechanism of cytotoxicity in different human cell lines in vitro. METHODS We incubated the following cell types for 24 h with increasing concentrations of S(+)-ketamine and racemic ketamine: (i) human Jurkat T-lymphoma cells overexpressing the antiapoptotic B-cell lymphoma 2 protein, (ii) cells deficient of caspase-9, caspase-8, or Fas-associated protein with death domain and parental cells, and (iii) neuroblastoma cells (SHEP). N-Methyl-d-aspartate (NMDA) receptors and caspase-3 cleavage were identified by immunoblotting. Cell viability and apoptotic cell death were evaluated flowcytometrically by Annexin V and 7-aminoactinomycin D double staining. Mitochondrial metabolic activity and caspase-3 activation were measured. RESULTS Ketamine, in a concentration-dependent manner, induced apoptosis in lymphocytes and neuroblastoma cell lines. Cell lines with alterations of the mitochondrial pathway of apoptosis were protected against ketamine-induced apoptosis, whereas alterations of the death receptor pathway did not reduce apoptosis. S(+)-Ketamine and racemic ketamine induced the same percentage of cell death in Jurkat cells, whereas in neuroblastoma cells, S(+)-ketamine was slightly less toxic. CONCLUSIONS Ketamine at millimolar concentrations induces apoptosis via the mitochondrial pathway, independent of death receptor signalling. At higher concentrations necrosis is the predominant mechanism. Less toxicity of S(+)-ketamine was observed in neuroblastoma cells, but this difference was minor and therefore unlikely to be mediated via the NMDA receptor.
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Affiliation(s)
- S Braun
- Department of Anesthesiology, University of Düsseldorf, Germany
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Abstract
Ketamine has found many applications in pediatric anesthetic practice. Insights into the mechanism of action and the pharmacokinetics and pharmacodynamics of its isomers have led to a re-evaluation of this drug, expanding the range of applications in children. Ketamine is a remarkably versatile drug that can be administered through almost any route. It can also be used for different purposes. The aim of this review is to look at the possible applications of this drug in children.
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Affiliation(s)
- James A Roelofse
- Division of Anesthesiology and Sedation, University of the Western Cape, Cape Town, South Africa.
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Murali Krishna T, Panda NB, Batra YK, Rajeev S. Combination of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in orthopaedic surgery. Eur J Anaesthesiol 2008; 25:299-306. [PMID: 17892610 DOI: 10.1017/s0265021507002645] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intrathecal ketamine produces a short period of analgesia with stable haemodynamics. Midazolam with bupivacaine prolongs the duration of analgesia when administered intrathecally but does not prevent hypotension. The objective of this study was to assess the effect of a combination of intrathecal bupivacaine, ketamine and midazolam on the duration of analgesia and haemodynamic parameters. METHODS A prospective, randomized, double-blind study was carried out in 60 ASA I and II patients undergoing lower limb surgery under spinal anaesthesia. Patients were divided into three groups of 20 each. Patients in all the three groups received 3 mL of hyperbaric bupivacaine (0.5%) intrathecally. In addition, patients in Groups II and III received intrathecal ketamine (0.1 mg kg-1) and the same dose of ketamine along with midazolam (0.02 mg kg-1), respectively. All patients were evaluated for block characteristics, duration of pain-free period, total rescue analgesic requirement in the 24-h postoperative period, total dose of mephenteramine to treat hypotension and any central or neurological complication. RESULTS No patients in Group II required mephenteramine while 40% of patients in Group I and 10% in Group III required mephenteramine to maintain blood pressure after spinal anaesthesia. The mean +/- standard deviation duration of pain-free period was 331.5 +/- 89.9, 369.7 +/- 124.2 and 730.5 +/- 81.5 min in Group I, II and III, respectively. The pain-free interval was significantly greater in Group III compared to Groups I and II (P < 0.001). No patient had any complications. CONCLUSION A low dose of midazolam and ketamine with bupivacaine intrathecally results in prolonged analgesia and less haemodynamic fluctuations. However, the safety of this combination needs to be proved before its use in clinical practice.
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Affiliation(s)
- T Murali Krishna
- Postgraduate Institute of Medical Education and Research, Department of Anaesthesia and Intensive Care, Chandigarh, India
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Wilson JA, Nimmo AF, Fleetwood-Walker SM, Colvin LA. A randomised double blind trial of the effect of pre-emptive epidural ketamine on persistent pain after lower limb amputation. Pain 2008; 135:108-18. [PMID: 17583431 DOI: 10.1016/j.pain.2007.05.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Revised: 05/09/2007] [Accepted: 05/14/2007] [Indexed: 01/19/2023]
Abstract
Persistent pain has been reported in up to 80% of patients after limb amputation. The mechanisms are not fully understood, but nerve injury during amputation is important, with evidence for the crucial involvement of the spinal N-methyl d-aspartate (NMDA) receptor in central changes. The study objective was to assess the effect of pre-emptively modulating sensory input with epidural ketamine (an NMDA antagonist) on post-amputation pain and sensory processing. The study recruited 53 patients undergoing lower limb amputation who received a combined intrathecal/epidural anaesthetic for surgery followed by a randomised epidural infusion (Group K received racemic ketamine and bupivacaine; Group S received saline and bupivacaine). Neither general anaesthesia nor opioids were used during the peri-operative period. Pain characteristics were assessed for 12 months. The primary endpoint was incidence and severity of post-amputation pain. Persistent pain at one year was much less in both groups than in comparable studies, with no significant difference between groups (Group K=21% (3/14) and 50% (7/14); and Group S=33% (5/15) and 40% (6/15) for stump and phantom pain, respectively). Post-operative analgesia was significantly better in Group K, with reduced stump sensitivity. The intrathecal/epidural technique used, with peri-operative sensory attenuation, may have reduced ongoing sensitisation, reducing the overall incidence of persistent pain. The improved short-term analgesia and reduced mechanical sensitivity in Group K may reflect acute effects of ketamine on central sensitisation. Longer term effects on mood were detected in Group K that requires further study.
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Affiliation(s)
- John A Wilson
- Department of Anaesthesia Critical Care and Pain Medicine, Clinical and Surgical Sciences, The University of Edinburgh, Royal Infirmary, Little France, Edinburgh EH16 4SA, UK
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Wang X, Xie H, Wang G. Improved postoperative analgesia with coadministration of preoperative epidural ketamine and midazolam. J Clin Anesth 2007; 18:563-9. [PMID: 17175423 DOI: 10.1016/j.jclinane.2006.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Revised: 03/03/2006] [Accepted: 03/06/2006] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To assess postoperative pain regulation and pharmacokinetic effects of preoperative administration of ketamine and midazolam. DESIGN Double-blind, randomized clinical study. SETTING University hospital. PATIENTS 46 ASA physical status I and II patients (age, 26-58 yrs), scheduled for gastrectomy. INTERVENTIONS Patients were randomly assigned to three treatment groups: a preoperative epidural injection of 10 mL (1) ketamine (0.5 mg/kg) solution (Ket group); (2) ketamine (0.5 mg/kg) plus midazolam (0.05 mg/kg) solution (KM group); or (3) normal saline solution (Ctr group). MEASUREMENTS Analgesic effects were evaluated by Visual Analog Scale (VAS) pain scores at rest, time to first request for analgesic (TFA), and morphine consumption during the initial postoperative time of 48 hours. Plasma concentration of ketamine in the Ket group and the KM group was measured by high-performance liquid chromatography, and the elimination half-life of ketamine was calculated. MAIN RESULTS Compared with the Ctr group, the Ket and KM groups had lower VAS pain scores, longer TFA, and lower morphine consumption. The KM group had the longest TFA and the lowest morphine consumption of the three groups. The KM group also had higher plasma concentrations of ketamine 90 to 240 minutes after injection, and a longer elimination half-life of ketamine, than did the Ket group. CONCLUSIONS Preoperative epidural coadministration of a low dose of ketamine with midazolam is more effective in relieving postoperative pain than using ketamine alone. In addition, epidural midazolam prolongs the elimination of ketamine.
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Affiliation(s)
- Xin Wang
- Department of Anesthesiology, General Hospital of Tianjin Medical University, Tianjin 300052, PR China.
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Ultrastructure of Canine Meninges After Repeated Epidural Injection of S(+)-Ketamine. Reg Anesth Pain Med 2006. [DOI: 10.1097/00115550-200609000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Visser E, Schug SA. The role of ketamine in pain management. Biomed Pharmacother 2006; 60:341-8. [PMID: 16854557 DOI: 10.1016/j.biopha.2006.06.021] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 06/12/2006] [Indexed: 01/21/2023] Open
Abstract
Ketamine is a dissociative anaesthetic; its mechanism of action is primarily an antagonism of the N-methyl-D-aspartate (NMDA) receptor. The role of ketamine, in particular in lower sub-anaesthetic doses, has recently gained increasing interest in pain management. It has been studied in a considerable number of trials and analysed in meta-analyses and systematic reviews. Based on these data, the primary role of ketamine in such low doses is as an 'anti-hyperalgesic', 'anti-allodynic' or 'tolerance-protective' agent. It therefore has a role in the treatment of opioid resistant or 'pathological' pain (central sensitisation with hyperalgesia or allodynia, opioid induced hyperalgesia, neuropathic pain) rather than as an 'analgesic' in its own right. Low dose ketamine also has 'preventive analgesia' properties. Furthermore, in higher doses it provides effective and safe sedation and analgesia for painful procedures. The place of ketamine in the treatment of chronic pain and the effects of long-term medicinal use remain unclear.
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Affiliation(s)
- E Visser
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, and University of Western Australia, School of Medicine and Pharmacology, Perth, WA 6847, Australia
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Lizarraga I, Chambers JP, Johnson CB. Depression of NMDA-receptor-mediated segmental transmission by ketamine and ketoprofen, but not L-NAME, on the in vitro neonatal rat spinal cord preparation. Brain Res 2006; 1094:57-64. [PMID: 16716267 DOI: 10.1016/j.brainres.2006.03.117] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Accepted: 03/29/2006] [Indexed: 11/20/2022]
Abstract
Activation of spinal N-methyl-D-aspartate (NMDA) receptors and then the nitric oxide and the arachidonic acid pathways is important in pain transmission. This study assessed the effects of the NMDA receptor channel blocker ketamine, the nitric oxide synthase inhibitor L-NAME, and the cyclooxygenase inhibitor ketoprofen in nociceptive transmission using an in vitro neonatal rat spinal cord preparation. Supramaximal electrical stimulation of the dorsal root evoked the A-fibre- and C-fibre-mediated high intensity excitatory postsynaptic potential (EPSP) in the ipsilateral ventral root. Low intensity stimulation evoked the A-fibre-mediated monosynaptic compound action potential (MSR) superimposed on the low intensity EPSP. Both the low intensity EPSP and the high intensity EPSP contain NMDA-receptor-mediated components. Only ketamine and ketoprofen depressed the synaptic responses. Ketamine depressed all three spinal reflexes with IC(50) values (with 95% CI) of 10.80 microM (5.97 to 19.54 microM) for the MSR, 8.29 microM (4.53 to 14.17 microM) for the low intensity EPSP, and 5.35 microM (3.05 to 9.40 microM) for the high intensity EPSP. Ketoprofen depressed the low intensity EPSP and the high intensity EPSP only; IC(50) values (with 95% CI) were 354.5 microM (217.5 to 576.8 microM) and 302.7 microM (174.0 to 526.7 microM), respectively. Reflexes recovered after drug washout. These data demonstrated that ketamine and ketoprofen, but not L-NAME, depressed NMDA-mediated nociceptive transmission in spinal cord preparations from neonatal rats.
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Affiliation(s)
- I Lizarraga
- IVABS, Massey University, Private Bag 11222, Palmerston North, New Zealand.
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Kozek SA, Sator-Katzenschlager S, Kress HG. Intrathecal S(+)-ketamine in refractory neuropathic cancer pain. Pain 2006; 121:283-284. [PMID: 16513276 DOI: 10.1016/j.pain.2006.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 01/11/2006] [Indexed: 10/25/2022]
Affiliation(s)
- S A Kozek
- Department of General Anesthesiology and Intensive Care B, Vienna Medical University, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Choi SS, Kim YC, Lim YJ, Lee CJ, Lee PB, Lee SC, Sim WS, Choi YL. The Neurological Safety of Epidural Gabapentin in Rats: A Light Microscopic Examination. Anesth Analg 2005; 101:1422-1426. [PMID: 16244005 DOI: 10.1213/01.ane.0000180197.32577.9b] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Gabapentin acts primarily on the central nervous system. Therefore, we hypothesized that the direct epidural administration of gabapentin could have various advantages over its oral administration with respect to required dose, side effects, and efficacy. However, before administering gabapentin into the epidural space in a clinical setting, its neurotoxicity must be examined in animals. Thus, we evaluated neurotoxicity of epidural gabapentin by observing behavioral and sensory-motor changes, and by histopathological examinations of spinal cords and dorsal root ganglia in the rat. Twenty-seven rats were randomly divided into 3 groups, which were administered 0.3 mL (30 mg) of epidural gabapentin (group G, n = 9) and the same volume of epidural alcohol (group A, n = 9) or normal saline (group N, n = 9). No rats in groups G and N showed sensory-motor dysfunction, behavioral change, or histopathological abnormalities over a 3-wk observation period, whereas all rats in group A showed abnormalities. We conclude that the direct epidural injection of gabapentin in rats did not show any neurotoxic evidence in terms of sensory-motor functions and behavior, or by a microscopic histopathological evaluation. This study represents a first promising step toward the trial of epidural gabapentin in a clinical setting.
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Affiliation(s)
- Sang-Sik Choi
- *Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine; and Departments of †Anesthesiology and Pain Medicine and ‡Diagnostic Pathology, SungKyunKwan University College of Medicine, Seoul, Korea
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Richebé P, Rivat C, Rivalan B, Maurette P, Simonnet G. Kétamine à faibles doses : antihyperalgésique, non analgésique. ACTA ACUST UNITED AC 2005; 24:1349-59. [PMID: 16115745 DOI: 10.1016/j.annfar.2005.07.069] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Recent data in animal experiments as in clinical trials have clearly reported that pain modulation is related to an equilibrium between antinociceptive and pronociceptive systems. Therefore, the apparent pain level could not only be a consequence of a nociceptive input increase but could also result from a pain sensitization process. Glutamate, via NMDA receptors, plays a major role in the development of such a neuronal plasticity in the central nervous system, leading to a pain hypersensitivity that could facilitate chronic pain development. By an action on NMDA receptors opioids also induce, in a dose dependent manner, an enhancement of this postoperative hypersensitivity. "Antihyperalgesic" doses of ketamine, an NMDA receptor antagonist, were able to decrease this central sensitization not only in painful animal but also in human volunteers exposed to different pain models, or in the postoperative period. Many studies have reported that ketamine effects are elicited when this drug is administered the following manner: peroperative bolus (0.1 to 0.5 mg/kg), followed by a constant infusion rate (1 to 2 microg/kg per min) during the peroperative period and for 48 to 72 hours after anaesthesia. Those ketamine doses improved postoperative pain management by reducing hyperalgesia due to both surgical trauma and high peroperative opioid doses. This antihyperalgesic action of ketamine also limited the postoperative morphine tolerance leading to a decrease in analgesic consumption and an increase in the analgesia quality.
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Affiliation(s)
- P Richebé
- Département d'anesthésie et de réanimation 3, hôpital Pellegrin, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
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38
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Vranken JH, Troost D, Wegener JT, Kruis MR, van der Vegt MH. Neuropathological findings after continuous intrathecal administration of S(+)-ketamine for the management of neuropathic cancer pain. Pain 2005; 117:231-5. [PMID: 16098665 DOI: 10.1016/j.pain.2005.06.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Revised: 06/06/2005] [Accepted: 06/13/2005] [Indexed: 11/21/2022]
Abstract
Questions have been raised about the potential neurotoxicity of the neuraxial use of ketamine although ketamine and its active enantiomer S(+)-ketamine have been used intrathecally and epidurally (caudally) for the management of perioperative pain and in a variety of chronic pain syndromes. Clinical experience following neuraxial administration of S(+)-ketamine has been documented without reference to local central nervous system toxicity following this approach. In addition, there are no preclinical safety data regarding stability, compatibility, and neurotoxicity on intrathecal use of single S(+)-ketamine or combinations of S(+)-ketamine, morphine, bupivacaine, and clonidine. In the present case, the continuous intrathecal administration of S(+)-ketamine, in combination with morphine, bupivacaine, and clonidine resulted in adequate pain relief in a patient suffering from intractable neuropathic cancer pain. However, postmortem observation of the spinal cord and nerve roots revealed severe histological abnormalities including central chromatolysis, nerve cell shrinkage, neuronophagia, microglial upregulation, and gliosis. Based on our results, neuraxial administration of S (+)-ketamine cannot be recommended for clinical practise before a systematic study of toxicology of neuraxial S(+)-ketamine in animals or humans has been performed.
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Affiliation(s)
- J H Vranken
- Department of Anesthesiology Academic Medical Center, University of Amsterdam P.O. Box 22700, 1100 DE Amsterdam, The Netherlands.
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Affiliation(s)
- Charles Lin
- Department of Anesthesiology, University of Virginia Health System Charlottesville, Charlottesville, VA 22908-0710, USA
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Smith WS, Dowd CF, Johnston SC, Ko NU, DeArmond SJ, Dillon WP, Setty D, Lawton MT, Young WL, Higashida RT, Halbach VV. Neurotoxicity of Intra-arterial Papaverine Preserved with Chlorobutanol Used for the Treatment of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Stroke 2004; 35:2518-22. [PMID: 15472097 DOI: 10.1161/01.str.0000144682.00822.83] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Papaverine is used to vasodilate cerebral arteries undergoing vasospasm from subarachnoid hemorrhage. However, papaverine inhibits cellular respiration in vitro and could cause neurotoxicity in humans. METHODS We studied 5 consecutive patients with cerebral vasospasm who were treated with intra-arterial papaverine preserved with chlorobutanol and imaged with MRI fluid-attenuated inversion recovery and diffusion-weighted imaging after treatment. One patient had histological analysis of the brain at autopsy. RESULTS All 5 patients exhibited marked neurological decline immediately after treatment, and this was sustained through hospital discharge. In all cases, MRI images showed selective gray matter-only signal changes within the vascular territory treated with papaverine. Histological analysis of 1 case brought to autopsy showed selective injury to islands of neurons with relative sparing of white matter. CONCLUSIONS Intra-arterial delivery of papaverine preserved with chlorobutanol into vasospastic anterior cerebral arteries may result in marked neurological deterioration with selective gray matter changes on MRI imaging. This effect is consistent with a permanent toxic effect to human brain. It is unclear whether this toxicity is caused by papaverine or chlorobutanol, and its use in the treatment of cerebral vasospasm should be reserved for cases without alternatives.
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Affiliation(s)
- Wade S Smith
- Department of Neurology, University of California, San Francisco, Calif 94134-0114, USA.
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Abstract
UNLABELLED Early preclinical work demonstrated the potential role of spinal benzodiazepine pharmacology in regulating spinal nociceptive transmission. We review this preclinical activity and the evolving implementation of intrathecal midazolam in humans for pain management. Important elements in this development for use in humans are issues pertinent to safety and the preclinical reports that have increased our understanding of intrathecal midazolam toxicity. We seek to emphasize the time course of these studies and how they merged to provide enabling data that drove the clinical implementation. In the case of midazolam, we point to the potential issues that arose when preclinical safety data were unreasonably ignored and how consideration of preclinical safety data can serve to facilitate drug development by demonstrating reasonable safety profiles that document the minimal degree of potential risk to the patient. Issues that are of continuing relevance to the use of intrathecal midazolam, including issues of formulation and kinetics, are considered. IMPLICATIONS The intrathecal use of midazolam has evolved over 20 years though a combination of preclinical and clinical investigations. We review the time course of this development to define critical elements that should be pursued in reducing the risk associated with the clinical use of a novel spinal drug.
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Affiliation(s)
- Tony L Yaksh
- Department of Anesthesiology, University of California, San Diego, La Jolla, California
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Martindale SJ, Dix P, Stoddart PA. Double-blind randomized controlled trial of caudal versus intravenous S(+)-ketamine for supplementation of caudal analgesia in children. Br J Anaesth 2004; 92:344-7. [PMID: 14742331 DOI: 10.1093/bja/aeh076] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The postoperative analgesic efficacy of S(+)-ketamine after caudal or i.v. administration following sub-umbilical surgery in children was studied to investigate its principal site of analgesic action. METHODS Sixty children undergoing caudal block during general anaesthesia for hernia repair or orchidopexy were prospectively randomized to one of three groups: the bupivicaine group received plain bupivacaine 0.25% 1 ml x kg(-1); the caudal ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) with S(+)-ketamine 0.5 mg x kg(-1); the i.v. ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) plus S(+)-ketamine 0.5 mg x kg(-1) i.v. Postoperative measurements included analgesic requirements and modified objective pain score for the first 24 h. RESULTS The median time to first analgesia was significantly longer in the caudal ketamine group (10 h) than in the i.v. ketamine (4.63 h) or bupivacaine (4.75 h) groups (P=0.01). Significantly fewer doses of analgesia were required over the first postoperative 24 h by subjects in the caudal ketamine group (median 1) compared with the i.v. ketamine (median 2) or bupivacaine (median 2.5) groups (P<0.05). There was no difference between the groups in the incidence of postoperative nausea and vomiting or psychomotor reactions. CONCLUSIONS We have demonstrated that the addition of caudal S(+)-ketamine to bupivacaine prolongs the duration of postoperative analgesia. However, the same dose of i.v. S(+)-ketamine combined with a plain bupivacaine caudal provides no better analgesia than caudal bupivacaine alone, indicating that the principal analgesic effect of caudal S(+)-ketamine results from a local neuroaxial rather than a systemic effect.
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Affiliation(s)
- S J Martindale
- Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
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Vranken JH, van der Vegt MH, Kal JE, Kruis MR. Treatment of neuropathic cancer pain with continuous intrathecal administration of S +-ketamine. Acta Anaesthesiol Scand 2004; 48:249-52. [PMID: 14995949 DOI: 10.1111/j.0001-5172.2004.00284.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effective treatment of patients suffering from neuropathic cancer pain remains a clinical challenge. When patients experience either insufficient analgesia or problematic side-effects after opioid administration, intrathecal administration of morphine and other medications such as bupivacaine and clonidine may offer significant advantages. Additionally, ketamine, a non-competitive N-methyl-D-Aspartate-receptor antagonist is able to alter pain perception at the spinal level. Because of the potential neurotoxicity after neuraxial use of racemic ketamine, intrathecal administration of the preservative-free active compound, S (+)-ketamine may be a valuable alternative. In this paper, we present a patient with severe neuropathic cancer pain successfully treated by continuous intrathecal infusion of morphine, bupivacaine, clonidine and S (+)-ketamine. Moreover, quality of life measurements before and 3 weeks after the start of spinal treatment revealed an improvement in pain relief and a higher overall quality of life. No clinical signs of neurologic deficit were observed during spinal treatment with S (+)-ketamine. However, the continuous intrathecal administration of S (+)-ketamine should be considered as the last resort because there are no preclinical safety data with relevant concentrations on intrathecal use of S (+)-ketamine.
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Affiliation(s)
- J H Vranken
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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Xie H, Wang X, Liu G, Wang G. Analgesic effects and pharmacokinetics of a low dose of ketamine preoperatively administered epidurally or intravenously. Clin J Pain 2003; 19:317-22. [PMID: 12966258 DOI: 10.1097/00002508-200309000-00006] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to compare the analgesic effects and pharmacokinetics of epidural versus intravenous administration of low doses of ketamine. METHODS 45 patients scheduled for selective gastrectomy were randomly assigned into 3 groups: 0.5mg/kg ketamine administered epidurally (Kepi group), 0.5 mg/kg ketamine administered intravenously (Kiv group), or 10ml normal saline administered epidurally (Ctr group). Analgesic effects were evaluated using Visual Analog Scale (VAS) pain scores at rest, time to first request for analgesic (TFA), and subsequent morphine consumption. The plasma concentration of ketamine was measured with high performance liquid chromatography (HPLC) in the Kepi and Kiv groups. The elimination half-life of ketamine was calculated. RESULTS Patients in the Kepi group had significantly lower VAS pain scores, longer TFA, and lower morphine consumption than patients in the Kiv or Ctr groups. Compared with intravenous administration, epidural administration of ketamine resulted in higher plasma concentrations from 90 minutes to 48 hours after injection, and much longer elimination half-life of ketamine, but a lower maximum plasma concentration of ketamine. CONCLUSION The results suggest that epidural administration of a low dose of ketamine provides more effective analgesic effects as seen post-operatively than intravenous administration. The prolonged half-life and high plasma sustained concentration of epidural ketamine might account for the difference in analgesic effects.
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Affiliation(s)
- Hong Xie
- Department of Neurobiology, State Key Laboratory of Medical Neurobiology, Medical Center of Fudan University, Shanghai, China
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Hoffmann VLH, Baker AK, Vercauteren MP, Adriaensen HF, Meert TF. Epidural ketamine potentiates epidural morphine but not fentanyl in acute nociception in rats. Eur J Pain 2003; 7:121-30. [PMID: 12600793 DOI: 10.1016/s1090-3801(02)00074-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Epidural opioids have been reported to provide superior analgesia in acute pain management. Despite the fact that the required doses are low, major side effects such as respiratory depression may still occur. In an effort to maximize analgesia and to minimize the rate of side effects, epidural NMDA receptor antagonists, especially ketamine, may be co-administered with opioids. This study investigated whether ketamine had beneficial effects on fentanyl- or morphine-induced antinociception in an acute pain model in rats. In male Wistar rats, an epidural catheter was placed under general anaesthesia. After 1 week the animals were subjected to the tail withdrawal reaction (TWR) test. After determination of the basal reaction latencies, fentanyl, morphine, ketamine or combinations of an opioid with ketamine were administered epidurally. TWR latencies were measured for up to 2h after treatment. Both opioids showed a dose related antinociceptive effect. Fentanyl had a fast onset and a short duration of action whereas the reverse was true for morphine. Ketamine exhibited only limited antinociceptive properties. In the combinations, ketamine improved morphine-induced antinociception both in terms of maximal possible effect (MPE) as well as in duration of action. The combination of fentanyl with ketamine did not result in any improvement, neither in terms of MPE nor in duration of action. Moreover, increasing doses of ketamine tended to decrease the MPE of various doses of fentanyl. These data confirm that ketamine, contrary to opioids, does not possess important antinociceptive properties in an acute test such as the TWR test. Furthermore, these data indicate that additive drugs such as ketamine may have different effects on different opioids.
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Affiliation(s)
- D A H de Beer
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JN, UK
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Abstract
BACKGROUND The aim of this study was to evaluate whether caudal s-ketamine would prolong analgesia together with caudal bupivacaine. METHODS Thirty children, ASA I-II, 1 month-9 years, scheduled for minor inguinal or penile surgery, were randomly assigned in a prospective, double-blind fashion to receive single shot caudal blockade by either bupivacaine 0.125% 1 ml.kg(-1) (group B, n = 15) or a mixture of bupivacaine 0.125% 1 ml.kg(-1) and preservative-free s-ketamine 0.5 mg.kg(-1) (group K, n = 15). Postoperative pain was assessed by means of an observational 10-point scoring system and analgesia was administered if the pain score exceeded a value of 3. RESULTS Within 24 h after caudal block 10 patients (67%) in group K and three patients in group B (20%) did not require additional analgesic medication (P < 0.01). There were no significant differences between the groups for incidence of haemodynamic changes. We did not observe any negative side-effects attributable to the caudal block or s-ketamine. CONCLUSIONS Addition of preservative-free s-ketamine 0.5 mg.kg(-1) to caudal bupivacaine 0.125% 1 ml.kg(-1) provides significant prolongation of analgesia without producing negative side-effects.
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Affiliation(s)
- Frank Weber
- Department of Anaesthesia, University of Regensburg, Regensburg, Germany.
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